trauma


I managed to make a mistake, argue with the attending and the chief about how to fix it, and get myself cursed out in front of what seemed like most of the ICU – a very attentive audience. Good thing I was wearing a surgical mask at the time, or my expressions of dismay and resentment would have been even more transparent, and I would have gotten in even more trouble. It ended well for the patient, at least. I still maintain that my solution would have worked, but in retrospect, arguing with the chief and the attending, at the same time, when I was in the wrong to start with, and they were having a bad day, was not exactly wise. By the end of the day we seemed to be on speaking terms, I with them, and they with me; which I suppose says something about how well we get along together, to be able to have a gigantic fight and still keep going.

Apart from that central explosion, nothing much else happened. I’m fortunately not on call tonight, which is ok with me, because the trauma pager is going off with one unhelmeted motorcycle or ATV accident after another. You may conclude that the weather is quite fine. Tomorrow morning I will have further evidence that young men are fools (for not wearing helmets) and/or sissies. (Because they all scream and cry about nonexistent or minor injuries. No one makes as much noise as the 20-yr-old guy with a broken clavicle and a lot of road rash; a woman the same age with an open tib-fib, or an older man with an open femur, or an elderly lady with 10 broken ribs, will all be much more stoic. I have had no sympathy for young men since the day that one of them had me persuaded he had a broken clavicle, a dozen broken ribs, and a broken femur, from the amount of noise he made; after giving him dilaudid, we got through CT and xray, and found that he had a cracked clavicle, and nothing else. Pfui.) (And I’ve injured myself in sports too, and didn’t scream for more than five minutes, so I’m allowed to talk.)

It was a Saturday night, and I was on the vascular service, so being on call meant I was covering the vascular patients, plus urology, plus plastics. Which can add up to a lot, if the urology attendings have decided to do a couple of radical prostatectemies and urological reconstructions before leaving for the weekend. Or if plastics is on call for traumatic injuries. Fortunately, urology was quiet, and plastics was only on for hand injuries, of which there were none.

So when, around midnight, five or six ATV accidents started coming in in short order, I had time to go help. I had one end of the trauma bay, and I got the third helicopter transport, a young man, fairly alert, with some scalp lacerations, lots of bruises and lacerations everywhere else, and a mangled left leg. ATLS protocol, by the book, didn’t show much of anything – except for that leg. The foot was hanging at a strange ankle, and the foot looked quite pale compared to the other side. No pulses were palpable and he could only wiggle the toes.

The orthopedic resident was moving from one stretcher to another, distributing splints, and making notes for who would get to go to the OR first. He cocked his head at this one. “I’m not getting any pulses here, perhaps you guys should consult vascular.” “It’s ok, I am vascular,” I told him. I had already dug up the hand-held doppler, which is the mainstay of vascular workup in the ER: if you can hear pulses, it’s not too bad; if you can neither feel nor hear the pulses, then the limb is truly ischemic and will be dead within a couple of hours (6 is usually quoted).

The trauma attending finally had time to get to that end of the bay. “This is a pretty bad open fracture. Can anyone feel pulses? Maybe we should consult vascular surgery.” “Yes sir, I am vascular; I was just helping out down here. I think it’s bad, there are no dopplerable pulses, and we’re about to call our attending.”

The situation was fairly textbook: an open fracture with clear distal ischemia. Don’t pass go, don’t collect $200 or any further studies, proceed straight to the OR. Since I had nothing better to do except sleep, I helped move the patient into the OR, and watched the orthopods fit the pieces back together and fasten them in place with an ex-fix (external fixator; like lego outside the leg; it stabilizes fractures, especially contaminated ones, for a couple of days, usually in preparation for definitive internal fixation; they’re cumbersome, and people often try to ignore their presence, but it’s actually easier for the patient if you move the leg by holding the ex-fix, since that won’t make the broken bones rub against each other, which is what really hurts).

Then, since my pager kindly remained silent, I got to help the vascular attending and chief (one of my heroes: smart, and good to work with), who were by this time fairly beat, since it was the fifth emergency case of the weekend. We prepped both legs, and the chief and I harvested the saphenous vein from the uninjured leg through a series of small incisions that we tunneled between to reach the whole vein, while the attending cleaned up around the injury on the other side, and found healthy artery on both sides for the anastomosis. He and the chief each took one end, and attached the saphenous vein to the healthy artery, while I started closing all the incisions on the other side. Ortho had already made the fasciotomies (long ugly slashes through the fascial covering of the four muscle compartments in the calf, necessary to relieve pressure and prevent ischemia after a serious injury or period of ischemia), so all we had to do on the injured side was wrap yards of kerlex and gauze around the entire structure of the ex-fix and our incisions, and we were done.

The poor vascular team still had two more cases to go, and I had to go attend to some urology patients about whom I had received no signout. It made for an incredibly long call day, but that was my favorite night to date: a dramatic, classical injury, which I got to follow from the door through the OR, and then round on for the next few days. Talk about continuity.

I continued my attempts to be in three places at the same time, to no one’s particular satisfaction. I ought to pick one place to be, and do a good job there, and then at least those people will be happy, instead of all three groups being displeased at once. I can’t somehow manage to 1) round with the attending in the trauma unit 2) discharge patients in another unit 3) be present for resuscitations in the ER, all at once. Result, patients are not discharged in a timely fashion, the unit attending is displeased because I’m not continually present, and don’t everything about all the unit patients, and the admitting attending is displeased because I’m rushing in and out of the resuscitations, and trying to get done with them as fast as possible so I can go back to the unit.

(In addition, there are a few secretarial jobs that the residents absolutely have to do, and somehow they’re always lowest on my list of priorities, which means the attendings who care about secretarial details will be out for my hide after a few more days of this neglect. I know it’s coming, and I still can’t find the time to get it done, even with spending 14-15hrs in the hospital.)

And I’m upset with myself, because I miss details on my own unit patients, and because the interns I’m supposed to be supervising turn up all day long with surprising statements like, “Shall we wait to do the CT scan till this patient has had the blood transfusion?” [what blood? I thought the count was just fine; why are you transfusing for that count? are there some symptoms I haven't heard about?] “I have to go talk to this patient’s family about discharging them to a nursing home tomorrow.” [nursing home? they're on the verge of sepsis; who said we could discharge them?] “This patient’s pain is not controlled on a fentanyl drip, what shall we do?” [how did they get on a fentanyl drip, and at that rate? how about some non-narcotic medications?] “I’m going to get a consent for a trach and peg on this patient.” [oh, nice; I thought we were going to extubate them in a few days; what went wrong?] And this kind of conversation ought not to be happening; I ought to know, and if I can’t find out for myself, I ought at least to keep close enough track of the interns that they tell me these things sooner. If I could stop running my hands through my hair when three people talk to me at once, perhaps it would encourage the interns to tell me things more.

On the plus side, I got to supervise a couple of procedures today, lines and chest tubes, and was able to refrain from saying too much, and then was able to complete things correctly when the interns stumbled. Which was reassuring to all concerned.

My sickest patient didn’t die overnight, which was a very nice thing to discover in the morning. That’s one ray of light for the day – he’s still around, still worrying all of us to pieces; but at least he’s there to be worried about.

A combination of nothing particularly bad happening overnight or during the day, and me getting in earlier, made the day pass a lot more smoothly.

Interns, junior residents, and chiefs, think about a service differently. Interns are focused on the set of patients assigned to them. They know they’re responsible for that group, but anything else is out of their comprehension, and indeed they’ll probably get shooed away if they spend too much time thinking about patients they haven’t been assigned. Junior residents feel responsible to keep an eye on the intern’s patients, but they also limit themselves to some extent, because they know that the chief feels ownership of the entire service, and they don’t want to violate the chief’s prerogatives by taking too much responsibility for the service as a whole.

The chief, on the other hand, knows that there is no one but him to be responsible for the entire affair. Yes, the attending is responsible, but he’ll manifest that by asking the chief about anything that comes up, and expecting a solid, coherent, well-researched answer. The chief has to keep an eye out for the details on every patient, no matter which resident they are “assigned” to. He has to know all the important lab and imaging results, and the treatment plan for everybody, because that’s what keeps the service alive. If he misses a patient, there’s no one else to catch it.

I’m cautiously trying to develop that attitude. I can’t do it much when a real chief is around, because they hate it when the junior residents supervise too much. But when there’s no chief, I’m the one who has to make sure nothing slips through the cracks: no one gets mislaid in the ER, no important lab results get neglected for half a day, consultants are called as appropriate, patients who are going to the OR are prepped for the OR, and inspected for damages upon their return. I’m gradually shaking the intern habit of tuning out when a patient I’m not “following” is being discussed.

I’m also developing an amazing appetite for reading the textbooks at night. I’d better know more about what I’m doing. Just taking people’s word that “this is what we usually do” is not enough.

Halfway through the morning: “Alice, what’s going on with this patient? Why don’t you know?” Alice mumbles something. “That’s no excuse. You’re filling the role of senior resident today. Take care of things.”

Uh, thanks. Thanks for mentioning the role change after I’m already in trouble. I knew I was the senior, I just didn’t realize how much the attendings count on the senior on an every day basis, which means how much they count on me, even when I’m not forewarned.

That was the beginning of the rest of the day. Back to as bad as life was in June, constantly behind, expectations on all hands – attendings, nurses, interns, medical students – that I’m not fulfilling. Patients that are not receiving the amount of care I want them to have. Jobs not getting done, because every time I pick one thing up, three other people call me about something else. And getting berated the whole time.

There’s something definitely broken inside my head. The more I get rebuked, the more I want to do better. Any rational person at this point would say, Who cares what the attendings think, their expectations are unreasonable and their comments are uncalled for, forget about them, I’ll do what I want, and let them deal with it. But no, all I can do is figure that, if they expect me to function as the chief, then I’ll come in earlier and plan to stay later, so I can do everything right. As frustrated as I am, I can’t stand not to beat this. I can be responsible for thirty+ patients, I can know everything about their labs and scans and current conditions, I can be in touch with a dozen different consulting teams whose residents understandably growl at me whenever I page them and change their answer whenever my attending asks; I can. Even if it means working fifteen hours a day all week. The chief does it, right? Why shouldn’t I?

Besides, that’s the only way life will get any better. The attendings sure won’t suddenly decide to leave me alone.

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?

Things are usually fairly quiet till 4 or 5pm; before that, you can get a couple of little old ladies falling down stairs, or old men falling over their canes (that’s actually what the trauma pager said). Depending on whether the neurosurgeons have a white cloud or a black cloud on call, they could get one or two operative subdural hematomas out of that list.

5pm, just when you’re wishing for dinner, is when the action starts. 39 year old female, MVC (motor vehicle crash). She was drunk, and everyone in the trauma bay wonders how she got that way at 5pm, and wouldn’t it be nice if we had the time to do that too (actually, I’m surprised how many of the staff voice this thought; you’d think we’d have learned by observation the dangers of drinking). She has a small post-traumatic subarachnoid hemorrhage, which is somehow much less lethal than the ruptured-aneurysm variety, so she gets a night in the ICU for observation. Next!

56 year old male, pedestrian vs. car. Depending on his luck, this could mean a variety of injuries. Tonight, a tib-fib fracture, a radius/ulna fracture, some facial lacs. He gets to spend the night, or maybe a couple nights, till ortho has time to fix his fractures. This time of year, they operate practically non-stop, and if you don’t have an open fracture, it may take a day or two to get to the top of the OR schedule.

91 year old female, MVC vs retaining wall. (Who let her drive? Amazing how many concerned family members show up once the damage is done.) Of course she’s taking coumadin; we’ll be lucky if she isn’t taking plavix too (notorious blood thinners; coumadin can be reversed, plavix can’t). Lucky for her, no intracranial hemorrhage, just an ankle fracture, with the incision of her knee replacement above it torn open, and a few nonsignificant vertebral fractures. Collar x12 weeks, OR in a few days with ortho. She can go to a floor, but it has to be a monitored floor, because of her atrial fibrillation, and we can’t tell whether she had some kind of cardiac event that caused her to black out or lose control of the car. That’s why cardiac enzymes are part of the laundry list of labs sent from the trauma bay.

Then, three in a rush: by helicopter, unhelmeted driver MCC (motorcycle crash), obtunded, open fractures; unhelmeted passenger MCC, intubated, closed fractures, distended abdomen; by ground, 89 year old man with a head bleed, from a nursing home via an outlying hospital. It’s the luck of the draw which one of them hits the door first. The old man has intracerebral contusions on the CT from the outside hospital, which we dutifully repeat: his mental status is deteriorating, he’ll be intubated by morning, and there’s nothing neurosurgery can do to help. Call the trauma ICU for a bed.

The motorcycle driver isn’t that obtunded once he arrives; drunk would be a more accurate term. Drunk enough to be quite cheerful, and not to understand what’s happened. He makes plenty of noise, though, when ortho shows up to reduce his fractures and splint them before taking him up to the OR.

His girlfriend is another story. She seems to have a head injury bad enough to have gotten intubated already, which makes the rest of the exam a little more difficult, since she can’t tell us what hurts. Neurosurgery is in the background, grumbling about her having gotten vecuronium for the intubation, and a couple hits of fentanyl for sedation/pain control on the helicopter ride over (because that obscures their exam, and besides the vital signs, there’s little more important about a trauma patient than getting a good neuro exam). Once they’ve finished giving the story, the chopper nurses can be heard muttering about the dangers of transporting a flailing patient in a confined space.

What few members of the trauma team haven’t split off with the other recent arrivals hurry through the protocol: pupils are equal, still reactive;  no blood in her ears, so it doesn’t look like a basilar skull fracture; lung sounds a bit diminished on one side, but it’s hard to tell in the commotion of the trauma bay; can’t be sure, so we’ll wait to put a chest tube till we see the chest xray (the xray technicians have a great knack for pushing themselves into the middle of the commotion and standing still until we notice and make way for them). Abdomen is distended, good peripheral pulses, maybe a bit weak – can we get a manual blood pressure please? – veins hard to stick, somebody put a femoral introducer in, give us some labs, hook up the rapid infuser; where’s the FAST? Someone pulls up the little ultrasound cart, designed to take a quick look at four spaces where there should be no free fluid; if you see a black line around the heart, or between the liver and kidney, or around the bladder, or between the spleen and kidney, you have hemopericardium or hemoperitoneum, and in an unstable patient, should go straight to the OR. She isn’t exactly unstable, her pressure’s staying at 100 with several liters of saline running, so we decide to take her to CT for a look at her head. CT shows various intraparenchymal contusions with tight ventricles from the swelling – neurosurgery states their desire to place a ventriculostomy as soon as she’s still in one place long enough – but the abdominal CT is the chief’s jackpot for the night: a shattered spleen, in four different pieces, with the dye from the iv contrast frankly extravasating around it. Call the OR, we have a trauma ex lap. Neurosurgery requests to be paged once she’s intubated, so they can do the ventric while we open the belly. . . Brief stop in the ER to arrange lines in order, dress a few gaping wounds, and let the OR open their instrument trays, and another piece of the team is off upstairs with her.

The pager is still going off. 58 year old male, fall, intoxicated, altered level of consciousness. 19 year old male, ATV accident, chest pain, shortness of breath. 87 year old female, fall at nursing home. 26 year old male, gunshot wound to the thigh. 28 year old male, gunshot wound to the chest. 20 year old male, stab wound to the abdomen. You never know what they really are. The 58 year old might arrive with such poor consciousness that he’s already been intubated. The ATV rider might have a pneumothorax, or nothing more than a bruised chest. The 87 year old female might have nothing wrong with her, or she might have a subdural, a C2 fracture, and a splenic laceration. The gunshot to the chest might arrive in traumatic arrest, or it might have grazed his side. It’s like a very bad Christmas nightmare – you never know what’s inside the package. And it isn’t even midnight yet; the real drunks will start showing up later.

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